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EINet Alert ~ Jan 15, 2010


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- 2010 Cumulative number of human cases of avian influenza A/H5N1
- WHO situation update on pandemic influenza H1N1
- Denmark: Pandemic influenza H1N1 found in pigs
- Germany & Serbia: Influenza vaccine orders scaled back
- Georgia: WHO to provide donated influenza vaccine
- Europe: Health officials, experts reject 'false pandemic' charges
- Australia (Western Australia): First case of oseltamivir resistant pandemic (H1N1) 2009 influenza
- Azerbaijan: Donated pandemic (H1N1) 2009 vaccine arrives
- China: Additional pandemic influenza H1N1 vaccine ordered
- China: Children under three offered free flu shots for holiday
- Japan: Peramivir IV antiviral approved
- Indonesia: Toddler saved from avian influenza (H5N1) virus infection; 162nd case
- Indonesia: CORRECTION IN LOCATION- Mass chicken deaths confirmed avian influenza H5N1 positive
- Mongolia: First country to get donated influenza vaccine
- North Korea: Aid group says pandemic H1N1 flu spreading
- UK: Government considering unloading surplus influenza vaccine
- Mexico: Fewer than half of pandemic H1N1 vaccines received
- USA: Campaign to increase pandemic H1N1 vaccinations among Native Americans
- USA: Government re-thinks pandemic H1N1 vaccine orders
- USA (Ohio): Low vaccine uptake in high-risk groups
- Global: WHO to field questions on pandemic response

2. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA

3. Articles
- Mandatory Influenza Vaccination of Health Care Workers: Translating Policy to Practice
- Initial Response of Health Care Institutions to Emergence of H1N1 Influenza: Experiences, Obstacles, and Perceived Future Needs
- Influenza virus infection among pediatric patients reporting diarrhea and influenza-like illness
- Evolution at a high imposed mutation rate: adaptation obscures the load in phage t7
- Drive-Through Medicine: A Novel Proposal for Rapid Evaluation of Patients During an Influenza Pandemic
- Extensive mammalian ancestry of pandemic (H1N1) 2009 virus

4. Notifications
- International Symposium on Neglected Influenza Viruses
- 14th International Congress on Infectious Diseases (ICID)
- ISHEID Symposium on HIV and Emerging Infectious Diseases
- CDC 7th International Conference on Emerging Infectious Diseases
- Options for the Control of Influenza VII
- Updated influenza guidance and information from the US CDC


1. Influenza News

Global
2010 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Total/ 0(0)

***For data on human cases of avian influenza prior to 2010, go to: http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 467 (282) (WHO 12/30/09 http://www.who.int/csr/disease/avian_influenza/country/cases_table_2009_12_30/)

Avian influenza age distribution data from WHO/WPRO (last updated 12/30/09): http://www.wpro.who.int/sites/csr/data/data_Graphs.htm

WHO's map showing world's areas affected by H5N1 avian influenza (status as of 9/24/09): http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2009_FIMS_20090924.png.

WHO's timeline of important H5N1-related events (last updated 1/4/10): http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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WHO situation update on pandemic influenza H1N1
As of 10 January 2009, worldwide more than 208 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including at least 13,554 deaths.

The most intense areas of pandemic influenza virus transmission currently are in parts of North Africa, South Asia, and east and southeastern Europe.

In North Africa, limited data suggest that transmission of pandemic influenza virus remains active throughout the region, particularly in Morocco, Algeria, and Egypt. In West Asia, limited data suggest that pandemic virus continues to circulate widely with a number of countries likely having already experienced a peak in activity prior to December. Pandemic H1N1 2009 virus continues to be the predominant circulating influenza virus in the northern African and western Asian regions with only sporadic detections of seasonal influenza viruses.

In South Asia, the northern and western parts of the subcontinent continued to experience active influenza transmission. In Nepal, increasing ARI activity and geographically regional to widespread influenza activity was reported during December and January. In India, overall activity may have peaked during mid to late December, however transmission has been regionally variable with a recently increasing trend in the western states, active but decreasing transmission in the northern states, and overall low activity in the eastern and southern states. In Sri Lanka, geographically widespread transmission with increasing trend of respiratory diseases was reported throughout December, however activity may have recently plateaued.

In Europe, pandemic influenza transmission remains geographically widespread throughout the continent, however, overall activity continued to decline substantially since November. A moderate intensity of respiratory diseases activity was reported in Romania, Ukraine, Turkey, and Switzerland; however, rates of ILI/ARI have been decreasing or have plateaued in all. At least four countries testing more than 20 sentinel respiratory specimens reported greater than 25% specimens were positive for influenza (Romania, Georgia, Germany, and France). The overall rate of specimens testing positive for influenza fell to 22% in Europe after reaching a peak of 45% during early November 2009. Pandemic H1N1 2009 virus continues to be the predominant circulating influenza virus in the European region with only sporadic detections of seasonal influenza viruses.

In East Asia, influenza activity remains widespread but continues to decline overall. In Japan, influenza activity remains elevated but has declined since peaking at the end of November 2009. Although influenza transmission remains active and regionally variable in China, overall activity has declined substantially since peaking during mid November 2009 in northern and southern China. In Hong Kong, influenza activity remained stably elevated but substantially lower than a large peak of activity during late September and early October 2009. In Mongolia, rates of ILI have been elevated above seasonal baseline since late October 2009 but declined substantially since a peak of activity was observed during November 2009. In DPR Korea, geographically regional influenza activity with increasing respiratory diseases trend was reported during early January 2010. Pandemic H1N1 continues to be the predominant circulating virus in the region but seasonal H3N2 viruses continue to circulate in very small numbers in northern China.

In the Americas, both in the tropical and northern temperate zones, overall pandemic influenza activity continued to decline or remain low. In North America, peak influenza activity occurred during early, mid, and late October in Mexico, the United States, and Canada, respectively. Small areas of increased influenza activity may be occurring in central and northern Mexico.

In temperate regions of the southern hemisphere, sporadic cases of pandemic influenza continued to be reported without evidence of sustained community transmission. This suggests that the level of population immunity in areas that experienced intense, high-level transmission during a winter season is high enough to prevent sustained transmission from recurring during the summer when the virus is less transmissible.
(WHO 1/15/2010)

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Europe/Near East
Denmark: Pandemic influenza H1N1 found in pigs
Approximately 3,000 piglets and 700 sows have tested positive for influenza A H1N1, according to the Danish Food and Veterinary Administration (DVFA). The DVFA has restricted the movement of animals from the affected farms for a period of a week until all signs of the infection have disappeared.

Since mid-2009, Denmark has become the twentieth country to report pandemic influenza A/H1N1 (2009) in animals to the World Organization for Animal Health (OIE).
(ProMED 1/11/2010)

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Germany & Serbia: Influenza vaccine orders scaled back
GlaxoSmithKline has confirmed that the German government is trimming its H1N1 vaccine order by 30%. Other governments are reducing their vaccine orders because they have surpluses owing to falling public demand and findings that one dose, rather than two, is enough to protect most people against the virus. In a related development, Serbia said 12 January 2009 it would stop importing vaccine and reassess its needs in February.
(CIDRAP 01/13/2010)

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Georgia: WHO to provide donated influenza vaccine
Public health officials in Georgia said the WHO will provide the country with 400,000 pandemic vaccine doses to immunize high-risk groups. Groups slated to receive the first doses include pregnant women, healthcare workers, and those with weakened immunity and chronic conditions. Pandemic flu activity is starting to decline in Georgia, but officials are warning that another wave of illnesses could occur.
(CIDRAP 01/13/2010)

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Europe: Health officials, experts reject 'false pandemic' charges
Leading public health officials and experts have sharply rejected charges from some European officials that pharmaceutical companies used exaggerated claims about the H1N1 pandemic threat to scare governments into buying unnecessary stockpiles of vaccines.

The Council of Europe's Social Affairs Committee has asked for a debate on the theme "False pandemics: a threat to health," according to a statement on the council's Web site. In the resolution, Dr Wolfgang Wodarg, a German physician and politician who chairs the Council of Europe's health committee, and 13 others charge that pharmaceutical companies have made countries "squander tight health care resources for inefficient vaccine strategies and needlessly exposed millions of healthy people to the risk of unknown side-effects of insufficiently tested vaccines." The group asked the council to investigate the claims.

The proposal has drawn quick and sharp responses from numerous top public health officials in the UK, Australia, and the USA who called it "ludicrous", "preposterous" and "irresponsible". While declining to comment on the European response, Walter R. Dowdle, MD, a former deputy director of the US Centers for Disease Control and Prevention (CDC), voiced strong support for the US response. "The fact that the 2009 H1N1 vaccine began to arrive as virus transmission began to decline, as in 1957 and 1968, speaks to the shortcomings of outmoded pandemic vaccine production methodology, not the public health decision making process," he said.
(CIDRAP 01/13/2010)

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Asia
Australia (Western Australia): First case of oseltamivir resistant pandemic (H1N1) 2009 influenza
A kidney transplant patient in Western Australia has died after developing Australia's first case of pandemic (H1N1) 2009 influenza resistant to oseltamivir (Tamiflu). The resistant virus contained the H275Y NA neuraminidase mutation, which is the only known mechanism for oseltamivir resistance in influenza virus infection. However, the virus appears to be sensitive to zanamivir (Relenza), according to Dr David Speers, Infectious Diseases Physician at the Sir Charles Gairdner Hospital in Perth.

The case report was published by the Medical Journal of Australia on 11 January 2010 [http://www.mja.com.au/public/issues/192_03_010210/spe11148_fm.html].
(ProMED 1/11/2010)

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Azerbaijan: Donated pandemic (H1N1) 2009 vaccine arrives
On 8 January 2010, Azerbaijan received its first shipment of donated pandemic (H1N1) 2009 vaccine, containing 172,000 doses out of a total of 860,000. The vaccine will be distributed to designated health facilities next week. Vaccination will target health care workers, the staff of life support services, pregnant women, people with a history of chronic lung disease and children aged 14-17.

WHO has coordinated the distribution of pandemic (H1N1) 2009 vaccine donated by several countries and vaccine manufacturers. Azerbaijan was one of the first countries to express an interest in receiving this emergency supply. Since doing so, the Government has prepared a vaccine deployment plan and signed a letter of agreement with WHO.
(WHO 1/11/2010)

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China: Additional pandemic influenza H1N1 vaccine ordered
China has ordered additional pandemic H1N1 vaccine from Sinovac Biotech Ltd., the company announced on 13 January 2010. The order is for 8.57 million doses and brings the total bought by the government from Sinovac to 20.05 million doses, of which 10.23 million have been delivered. The order calls for the company to deliver 2.33 million doses by Mar 15 and to stockpile the rest in its own warehouse, officials said.
(CIDRAP 01/13/2010)

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China: Children under three offered free flu shots for holiday
China's Ministry of Health said that the government will fund free H1N1 flu vaccinations for all children in the country who are less than three years old. The central government made the move in anticipation of Lunar New Year celebrations, when millions of people travel to visit relatives. China has vaccinated 51.4 million residents so far.
(CIDRAP 1/8/2010)

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Japan: Peramivir IV antiviral approved
Japan has approved peramivir, an intravenous neuraminidase inhibitor, for the treatment of adults with influenza, Shionogi & Co., Ltd. announced 13 January 2010. Shionogi has licensed the drug from US-based BioCryst. Japan is the first country to approve peramivir, though in October the US Food and Drug Administration (FDA) granted it an emergency use authorization. Shionogi said it finished a clinical trial of the drug in children and intends to file an application for pediatric use within the next fiscal year.
(CIDRAP 01/13/2010)

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Indonesia: Toddler saved from avian influenza (H5N1) virus infection; 162nd case
A medical team at RSUD Arifin Achmad public hospital in Pekanbaru, Riau, has succeeded in saving the life of a four-year-old child from avian influenza (H5N1) virus infection. The hospital is currently treating a 17-year old boy who is also suspected to have an H5N1 infection.

The toddler, who had physical contact with a dead chicken in her backyard, reportedly tested positive for H5N1 infection in laboratory tests performed by the Health Ministry's Research and Development Agency. This would be the 162nd since 2005 and the first in 2010.
(ProMED 01/12/2010)

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Indonesia: CORRECTION IN LOCATION- Mass chicken deaths confirmed avian influenza H5N1 positive
[The previous report erroneously indicated "South Kalimantan" province as the location of the described outbreaks, whereas the outbreaks were in fact located in the Central Kalimantan province. The corrected text follows.]

6,615 chickens died in seven sub-districts in the province of Central Kalimantan between early December 2009 and 3 January 2010. H5N1 avian influenza was suspected and confirmed in specimens tested by the Veterinary Investigation and Diagnostic Center (BPPV) Regional V, Banjarbaru, South Kalimantan. To date, this outbreak has been limited to chickens. No bird to human virus transmission has been reported.
(ProMED 1/10/2010)

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Mongolia: First country to get donated influenza vaccine
On 7 January 2010, Mongolia became the first developing country to receive donated doses of H1N1 vaccine from the WHO. The first 35 countries on the list to receive vaccine should all get supplies within the next month, said WHO spokeswoman Nyka Alexander. Azerbaijan and Afghanistan are expected receive doses within days. The WHO has received pledges for 190 million doses from 14 countries.
(CIDRAP 1/8/2010)

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North Korea: Aid group says pandemic H1N1 flu spreading
H1N1 flu is continuing to spread in Pyongyang, North Korea, prompting the closure of day care centers and kindergartens, an aid group called Good Friends reported on the UN-sponsored ReliefWeb site. Quoting an unnamed official, the report said some children have died and severe winter weather has worsened the situation. The group also said flu medications sent from South Korea have been used mainly in Pyongyang, with little reaching the provinces, where the virus is also spreading.
(CIDRAP 1/11/2010)

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UK: Government considering unloading surplus influenza vaccine
The British government is looking at ways to "offload" millions of doses of H1N1 vaccine because a third wave of cases is deemed unlikely. Options include selling the surplus doses or giving them to poor countries, but a stockpile will be kept. The government bought 60 million doses from GlaxoSmithKline and 30 million from Baxter. So far, 23.9 million doses of GSK vaccine and five million doses of Baxter vaccine have been delivered.
(CIDRAP 1/8/2010)

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Americas
Mexico: Fewer than half of pandemic H1N1 vaccines received
Mexico, site of the world's first pandemic H1N1 cases, has received fewer than half of the 30 million doses of vaccine it ordered in 2009, Health Secretary Jose Angel Cordova said 11 January 2010. He said Mexico has struggled to get the vaccine because it has to import it. So far the country has obtained 12 million doses, including a loan of 5 million from Canada. Cordova said the government hopes to vaccinate 24 million people by March.
(CIDRAP 01/12/2010)

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USA: Campaign to increase pandemic H1N1 vaccinations among Native Americans
Influenza pandemic (H1N1) 2009 virus infection kills Native Americans and Alaskan Natives at four times the rate of the rest of the population, making immunizations critical for native people, say national health experts. "The virus has hit Indian Economy especially hard," said Kathleen Sebelius, United States Health and Human Services (HSS) Secretary. Sebelius joined Dr. Yvette Roubideaux, director of Indian Health Services, and Dr. Ralph Bryan of the Centers for Disease Control and Prevention (CDC), in a teleconference on 12 Jan 2010 to introduce HHS's new public service announcements. The announcements, starring Cherokee [Native American] actor Wes Studi, focus on promoting pandemic H1N1 immunization in native populations.

Sebelius said more Native Americans die from pandemic H1N1 complications because the population has a higher rate of underlying health issues, such as asthma, diabetes and heart disease. These health issues, combined with an inability to access healthcare in remote reservation communities, put Native Americans at greater risk. But it's a risk that can be lessened with pandemic H1N1 immunizations, Sebelius said. With a third wave of the virus expected, the Indian Health Services, HHS and CDC are warning Native people not to become complacent in light of the current lull in flu cases. "It's an essential lifesaving message," Sebelius said. "Get vaccinated now."
(ProMED 1/13/2010)

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USA: Government re-thinks pandemic H1N1 vaccine orders
The United States said on 11 Jan 2010 it had cut in half its order for influenza pandemic (H1N1) 2009 virus vaccine from Australia's CSL Ltd, but said it is not certain how far orders from other suppliers will be trimmed. While U.S. officials are still calculating how much H1N1 flu vaccine they will need, it is becoming increasingly clear that the United States will not need all 251 million doses it ordered from 5 companies. CSL Ltd said the U.S. government was halving its order for pandemic H1N1 vaccines, partly because the company had diverted some of its early output to the Australian government and would not be able to deliver its full USD 180 million U.S. contract.

Original orders for flu vaccine were placed in May, June and July 2009, when it was not known what dose would be needed and it was not clear how severe the pandemic would be. Bill Hall, a spokesman for the U.S. Health and Human Services Department, said U.S. officials were talking with companies about how much to cut orders. "All the contracts that were put in place were designed to be flexible," Hall said in a telephone interview." "There is a balancing act to ensuring we have enough vaccine for the population to meet the demand." The United States has received 136 million doses of pandemic H1N1 vaccine from its 5 suppliers -- CSL, Glaxo, Sanofi, AstraZeneca unit MedImmune and Novartis, and the U.S. Centers for Disease Control and Prevention says more than 60 million people have been vaccinated.
(ProMED 1/12/2010)

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USA (Ohio): Low vaccine uptake in high-risk groups
Pandemic flu vaccine uptake in Ohio's high-risk groups has been low, according to a report in the Cleveland Plain Dealer. Only 20% of those at high risk for flu complications had been vaccinated through the end of the December, according to data from public records. For example, fewer than 2 in 10 of the state's pregnant women had received their immunization. As of Dec 30 the state had distributed four million doses and administered one million.
(CIDRAP 1/10/2010)

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Global: WHO to field questions on pandemic response
In response to some European officials who have questioned its response to the flu pandemic, the WHO said it will order an independent review, but probably not until after the pandemic is over. A WHO spokeswoman said its executive board will address questions on the topic at its Jan 18 meeting. Some members of the Council of Europe have charged that vaccine companies pressured the WHO and have called for an investigation.
(CIDRAP 1/12/2010)

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2. Updates
INFLUENZA A/H1N1
- WHO
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions: http://www.who.int/csr/disease/swineflu/frequently_asked_questions/en/index.html
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
http://www.who.int/csr/disease/influenza/pipguidance2009/en/index.html
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html.

- WHO regional offices
Africa: http://www.afro.who.int/
Americas: http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=805&Itemid=569
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Europe: http://www.euro.who.int/influenza/ah1n1
South-East: http://www.searo.who.int/EN/Section10/Section2562.htm
Western Pacific: http://www.wpro.who.int/health_topics/h1n1/

- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: http://www.flu.gov
MOH México: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: http://fightflu.ca

- Other useful sources
CIDRAP: Influenza A/H1N1 page: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promedmail.org/

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AVIAN INFLUENZA
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP's web site for information on fund management and administrative services. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza H5N1.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help health officials prepare for an influenza pandemic.
- The US government's website for pandemic/avian flu: http://www.flu.gov/. "Flu Essentials" are available in multiple languages.
- CIDRAP: http://www.cidrap.umn.edu/. Center for Infectious Disease Research and Policy based at the University of Minnesota.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en. The Virtual Health Library's Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp Read about the latest news on avian influenza H5N1 in wild birds and poultry.

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3. Articles
Mandatory Influenza Vaccination of Health Care Workers: Translating Policy to Practice
Babcock HM, Gemeinhart N, Jones M, et al. Clin Infect Dis. 11 Jan 2010. [Epub ahead of print]
Available at http://www.journals.uchicago.edu/doi/pdf/10.1086/650752

Background. Influenza vaccination of health care workers has been recommended since 1984. Multiple strategies to enhance vaccination rates have been suggested, but national rates have remained low.

Methods. BJC HealthCare is a large Midwestern health care organization with approximately 26,000 employees. Because organizational vaccination rates remained below target levels, influenza vaccination was made a condition of employment for all employees in 2008. Medical or religious exemptions could be requested. Predetermined medical contraindications include hypersensitivity to eggs, prior hypersensitivity reaction to influenza vaccine, and history of Guillan-Barré syndrome. Medical exemption requests were reviewed by occupational health nurses and their medical directors. Employees who were neither vaccinated nor exempted by 15 December 2008 were not scheduled for work. Employees still not vaccinated or exempt by 15 January 2009 were terminated.

Results. Overall, 25,561 (98.4%) of 25,980 active employees were vaccinated. Ninety employees (0.3%) received religious exemptions, and 321 (1.2%) received medical exemptions. Eight employees (0.03%) were not vaccinated or exempted. Reasons for medical exemption included allergy to eggs (107 [33%]), prior allergic reaction or allergy to other vaccine component (83 [26%]), history of Guillan-Barré syndrome (15 [5%]), and other (116 [36%]), including 14 because of pregnancy. Many requests reflected misinformation about the vaccine.

Conclusions. A mandatory influenza vaccination campaign successfully increased vaccination rates. Fewer employees sought medical or religious exemptions than had signed declination statements during the previous year. A standardized medical exemption request form would simplify the request and review process for employees, their physicians, and occupational health and will be used next year.

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Initial Response of Health Care Institutions to Emergence of H1N1 Influenza: Experiences, Obstacles, and Perceived Future Needs
Lautenbach E, Saint S, Henderson DK, Harris AD. Clin Infect Dis. 11 Jan 2010. [Epub ahead of print]
Available at http://www.journals.uchicago.edu/doi/pdf/10.1086/650169.

Background. The emergence of H1N1 influenza is cause for great concern. Although one of the most important components of the response to the H1N1 crisis is the work of health care epidemiology professionals, the beliefs and experiences of this community are unknown, and the optimal approach to managing H1N1 in the future has not been delineated.

Methods. To assess attitudes and responses of health care epidemiology professionals to the H1N1 influenza crisis, we conducted a cross-sectional survey of members of the Society for Healthcare Epidemiology of America. We assessed beliefs regarding (1) importance of H1N1, (2) institutional preparedness, (3) time spent on the H1N1 crisis, and (4) the institution's response to H1N1.

Results. Of 323 respondents, 195 (60.4%) reported that their hospitals were well prepared for a pandemic. Furthermore, the majority reported that senior administrators provided adequate political support and resources (85.1% and 80.2%, respectively) to respond to H1N1. However, 163 (50.9%) respondents reported that other important infection prevention activities were neglected during the H1N1 crisis. Shortages of antiviral medication were reported by 99 (30.7%) respondents. Furthermore, 126 (39.0%) reported that personal stockpiling of antiviral medications occurred at their institution, and 166 (51.4%) reported that institutional actions were initiated to prevent personal stockpiling. Also, 294 (91.0%) respondents believed that H1N1 influenza would reappear later this year. Vaccine development, health care worker education, and revisions of pandemic influenza plans were identified as the most important future initiatives. Finally, 251 (77.7%) respondents felt that health care workers should be mandated to receive influenza vaccine.

Conclusions. Although generally institutions are well prepared for the H1N1 crisis, substantial revisions of pandemic preparedness plans appear to be necessary. Future efforts to optimize the response to H1N1 should include curtailing personal stockpiling of antivirals and vaccine development with consideration of mandatory vaccination of health care workers.

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Influenza virus infection among pediatric patients reporting diarrhea and influenza-like illness
Dilantika C, Sedyaningsih ER, Kasper MR, et al. BMC Infect Dis. 7 Jan 2010;10(1):3. [Epub ahead of print]
Provisional PDF available at http://www.biomedcentral.com/content/pdf/1471-2334-10-3.pdf.

Background. Influenza is a major cause of morbidity and hospitalization among children. While less often reported in adults, gastrointestinal symptoms have been associated with influenza in children, including abdominal pain, nausea, vomiting, and diarrhea.

Methods. From September 2005 and April 2008, pediatric patients in Indonesia presenting with diarrhea and influenza-like illness were enrolled in a study to determine the frequency of influenza virus infection in young patients presenting with symptoms less commonly associated with an upper respiratory tract infection (UTI). Stool specimens and upper respiratory swabs were assayed for the presence of influenza virus.

Results. Seasonal influenza A or influenza B viral RNA was detected in 85 (11.6%) upper respiratory specimens and 21 (2.9%) of stool specimens. Influenza B virus was isolated from the stool specimen of one case. During the time of this study, human infections with highly pathogenic avian influenza A (H5N1) virus were common in the survey area. However, among 733 enrolled subjects, none had evidence of H5N1 virus infection.

Conclusions. The detection of influenza viral RNA and viable influenza virus from stool suggests that influenza virus may be localized in the gastrointestinal tract of children, may be associated with pediatric diarrhea and may serve as a potential mode of transmission during seasonal and epidemic influenza outbreaks.

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Evolution at a high imposed mutation rate: adaptation obscures the load in phage t7
Springman R, Keller T, Molineux IJ, Bull JJ. Genetics. Jan 2010;184(1):221-32. [Epub 2009 Oct 26]
Available at http://www.genetics.org/cgi/content/full/184/1/221.

Abstract. Evolution at high mutation rates is expected to reduce population fitness deterministically by the accumulation of deleterious mutations. A high enough rate should even cause extinction (lethal mutagenesis), a principle motivating the clinical use of mutagenic drugs to treat viral infections. The impact of a high mutation rate on long-term viral fitness was tested here. A large population of the DNA bacteriophage T7 was grown with a mutagen, producing a genomic rate of 4 nonlethal mutations per generation, two to three orders of magnitude above the baseline rate. Fitness-viral growth rate in the mutagenic environment-was predicted to decline substantially; after 200 generations, fitness had increased, rejecting the model. A high mutation load was nonetheless evident from (i) many low- to moderate-frequency mutations in the population (averaging 245 per genome) and (ii) an 80% drop in average burst size. Twenty-eight mutations reached high frequency and were thus presumably adaptive, clustered mostly in DNA metabolism genes, chiefly DNA polymerase. Yet blocking DNA polymerase evolution failed to yield a fitness decrease after 100 generations. Although mutagenic drugs have caused viral extinction in vitro under some conditions, this study is the first to match theory and fitness evolution at a high mutation rate. Failure of the theory challenges the quantitative basis of lethal mutagenesis and highlights the potential for adaptive evolution at high mutation rates.

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Drive-Through Medicine: A Novel Proposal for Rapid Evaluation of Patients During an Influenza Pandemic
Weiss E, Ngo J, Gilbert G, Quinn J. Ann Emerg Med. Jan 2010; [Epub ahead of print]
Available at http://www.annemergmed.com/webfiles/images/journals/ymem/eaweiss.pdf.

Study objective. During a pandemic, emergency departments (EDs) may be overwhelmed by an increase in patient visits and will foster an environment in which cross-infection can occur. We developed and tested a novel drive-through model to rapidly evaluate patients while they remain in or adjacent to their vehicles. The patient's automobile would provide a social distancing strategy to mitigate the person-to-person spread of infectious diseases.

Methods. We conducted a full-scale exercise to test the feasibility of a drive-through influenza clinic and measure throughput times of simulated patients and carbon monoxide levels of staff. We also assessed the disposition decisions of the physicians who participated in the exercise. Charts of 38 patients with influenza-like illness who were treated in the Stanford Hospital ED during the initial H1N1 outbreak in April 2009 were used to create 38 patient scenarios for the drive-through influenza clinic.

Results. The total median length of stay was 26 minutes. During the exercise, physicians were able to identify those patients who were admitted and discharged during the real ED visit with 100% accuracy (95% confidence interval 91% to 100%). There were no significant increases of carboxyhemoglobin in participants tested.

Conclusion. The drive-through model is a feasible alternative to a traditional walk-in ED or clinic and is associated with rapid throughput times. It provides a social distancing strategy, using the patient's vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases.

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Extensive mammalian ancestry of pandemic (H1N1) 2009 virus
Ilyushina NA, Kim J-K, Negovetich NJ, et al. Emerg Infect Dis. Feb 2010; [Epub ahead of print]
Available at http://www.cdc.gov/eid/content/16/2/pdfs/09-1141.pdf.

Abstract. We demonstrate that the novel pandemic influenza (H1N1) viruses have human virus-like receptor specificity and can no longer replicate in aquatic waterfowl, their historic natural reservoir. The biological properties of these viruses are consistent with those of their phylogenetic progenitors, indicating longstanding adaptation to mammals.

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4. Notifications
International Symposium on Neglected Influenza Viruses
Amelia Island, Florida, USA, 3-5 Feb 2010
The International Symposium on Neglected Influenza Viruses will bring together international scientists whose work focuses on mammalian influenza viruses from nonhuman/nonavian sources. You are invited to submit an abstract of original research in all areas related to nonhuman/nonavian influenza research for oral or poster presentation.
For a complete conference program, registration, and abstract submission information visit https://www.isirv.org/events/neglected-influenza/.

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14th International Congress on Infectious Diseases (ICID)
Miami, Florida, USA; 9-12 Mar 2010
Take advantage of reduced registration fees by registering on or before January 15, 2010.
Additional information and registration available at http://www.isid.org/14th_icid/.

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ISHEID Symposium on HIV and Emerging Infectious Diseases
Marseille, France, 24-26 Mar 2010
Tackling each topic from basic science to clinical applications, this meeting will deal with issues of HIV/AIDS, Viral Hepatitis, Emerging Infectious Diseases, and welcome many Key Opinion Leaders.
Additional information and registration available at http://www.isheid.com/.
The ISHEID 2010 congress organizing office...
E-mail: isheid@clq-group.com; Ph. : +33 1 44 64 15 15 - Fax : +33 1 44 64 15 16

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CDC 7th International Conference on Emerging Infectious Diseases
Atlanta, Georgia, USA 11-14 Jul 2010
The 2010 International Conference on Emerging Infectious Diseases (ICEID) is the principal meeting for emerging infectious diseases organized by CDC. This conference includes plenary and panel sessions, as well as oral and poster presentations, and covers a broad spectrum of infectious diseases of public health relevance. ICEID 2010 will also focus on the impact of various intervention and preventive strategies that have been implemented to address emerging infectious disease threats.
Additional information is available at http://www.iceid.org/.

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Options for the Control of Influenza VII
Hong Kong, 3-7 Sep 2010
Options for the Control of Influenza VII is the largest forum devoted to all aspects of the prevention, control, and treatment of influenza. As it has for over 20 years, Options VII will highlight the most recent advances in the science of influenza. The scientific program committee invites authors to submit original research in all areas related to influenza for abstract presentation. Accepted abstracts will be assigned for oral or poster presentation.
Additional information is available at http://www.controlinfluenza.com.

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Updated influenza guidance and information from the US CDC
Open Letter to the American People about the H1N1 Flu Vaccine
Released 11 January 2010
Available at http://www.cdc.gov/h1n1flu/open_letter_h1n1_vaccine.htm.

AUDIO: 30 second Radio-ready PSA - Vaccinate Against H1N1 Flu
Released 11 January 2010
Available at http://www2c.cdc.gov/podcasts/download.asp?af=h&f=667013.

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 apecein@u.washington.edu